(a) When a pharmacy benefits manager conducts an audit of a pharmacy, the pharmacy benefits manager shall base a finding of overpayment or underpayment by the pharmacy on the actual overpayment or underpayment and not on a projection based on the number of patients served having a similar diagnosis or on the number of similar orders or refills for similar drugs, except as provided in (b) of this section. (b) A pharmacy benefits manager may resolve a finding of overpayment or underpayment by entering into a settlement agreement with the pharmacy. The settlement agreement (1) must comply with the requirements of AS 21.36.125; and (2) may be based on a statistically justifiable projection method. (c) A pharmacy benefits manager may not include the dispensing fee amount in a finding of an overpayment unless (1) a prescription was not actually dispensed; (2) the prescriber denied authorization; (3) the prescription dispensed was a medication error by the pharmacy; or (4) the identified overpayment is solely based on an extra dispensing fee.
Alaska Legal Code